How To Create a Patient Medical Summary Report

Having a medical summary report available when caring for a person with health issues helps everyone in the care circle provide proper medical care. Often times such as with Alzheimer’s disease, the patient is unable to accurately communicate their past and present medical situation so it essential to have a mechanism in place that does this for them.

As discussed in my article, Patient Care Plans – A Vital Tool for Caregiving, a care plan is comprised of 3 components:

1. Patient Medical Summary Report
2. Patient Medical Action Plan
3. Patient Daily Care Plan

As a caregiver, you will be able to handle most things without much help in the beginning. But as the disease progresses, it will become unhealthy for both you and your loved one if you do not create a care circle around them. The care circle includes both paid and unpaid care providers such as family, doctors, or pharmacist.

In order for each care provider to give proper medical attention, they must be aware of the care recipient’s medical situation. A medical summary provides this communication in a format that everyone can understand.

A good medical summary will include two components: 1) log of all medications and 2) record of past and present medical conditions. Information covered in these components will include:

1. Contact information for doctors, pharmacy, therapists, dentist – anyone involved in their medical care
2. Current diagnosis
3. Medications and dosages including prescribed, over the counter, herbal, etc.
4. Allergies to medications, food, environment, etc.
5. All health issues and treatment plans
6. Latest test results such as blood pressure or cholesterol
7. Past medical issues
8. Major surgeries with dates
9. Family medical history
10. Medicare, medicade, or any other insurance policy numbers
11. Any medical devices that they may use
12. Health Care Directive (Living Will)
13. Medical Power of Attorney

Get started with emergency contacts and medications by using the medicine record resource below which was created by the FDA:
My Medicine Record

Then expand upon it with this great resource by Next Step in Care, an online resource for caregivers to log medical history (select the language of choice to download):
Your Family Member’s Personal Health Record

Continue reading this series by selecting this article:
How to Create a Patient Medical Action Plan

Questions, comments, or perhaps other ideas? In the comments below, I would love to hear from you.

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